AMGA: Tie Medicare Reimbursement to Care Coordination Metrics

September 07, 2016 - According to two comment letters to CMS, the American Medical Group Association (AMGA) has urged the federal agency to better align Medicare reimbursements and value-based incentive payments to promote enhanced care coordination.

The industry group provided critiques of proposed changes to the 2017 Physician Fee Schedule and the Hospital Outpatient Prospective Payment System.

“AMGA members are at the forefront of providing integrated and patient-centered care,” said President & CEO Donald W. Fisher, PhD, CAE. “Our comments today offer insight on how CMS can refine its proposals on behavioral health, chronic care management, and accountable care organizations to further care coordination and care integration for patients.”

In its letter on the proposed Physician Fee Schedule for 2017, AMGA emphasized that Medicare reimbursement rates should pay providers for actual resources used to coordinate care and called on the agency to promote coordinated chronic disease management and integrated behavioral healthcare.

The proposed rule would modify the implementation of the Chronic Care Management code from 2014, which would pay providers for at least 20 minutes per month, per patient for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic diseases. But AMGA stated that the 20-minute limit may not reflect all the resources used to treat patients, especially since time spent on each patient varies based on medical complexity.

The organization advised CMS to “more accurately assess the amount of time spent in providing chronic care management activities” and increase Medicare reimbursement rates to support care coordination efforts. A cited study from the September 2015 issue of the Annals of Internal Medicine found that healthcare costs related to chronic care management services would “rapidly increase” as patient enrollment increased.

In response, CMS has proposed to pay providers for other codes in the Current Procedural Terminology family of chronic care management services.

AMGA also expressed concerns that the providers can only use chronic care management codes if beneficiaries have paid a 20 percent copay. Members have reported that it is challenging to “make known or enforce the copay requirement because these services had been previously provided for free.” The treatments should be considered a preventative service to ease concerns that providers will not be able to collect patient financial responsibilities, the organization stated.

In addition to chronic disease management, AMGA urged CMS to take a “lenient view” on paying primary care providers for initiating a behavioral health visits in order to enhance integrated healthcare.

Starting in 2017, CMS proposed to separately pay for services using three new codes under the Collaborative Care Model as well as a new code for care management treatments would reimburse for “services furnished using a broader application of behavioral health integration in the primary care setting.”

However, AMGA noted that primary care providers oftentimes have trouble increasing access to behavioral healthcare because patients tend to have an acute medical problem with more pressing medical needs, accessibility issues, and low appointment attendance. CMS should, therefore, be more flexible with primary care payments for initiating behavioral health visits.

The time limitations on the new code, AMGA added, should also account for other clinical features involved in the visits, including standardized screening tools, evidence-based care protocols, care managers, patient and family education, ongoing monitoring of patient status, and continuous performance measurement and improvement.

Additionally, AMGA asked CMS to align future appropriate use criteria and clinical decision-support mechanisms for advanced diagnostic imaging services with MACRA’s proposed Merit-Based Incentive Payment System. Under MACRA, providers will be able to earn value-based incentive payments through appropriate resource use and coordinating the appropriate use criteria with MACRA would reduce administrative burdens.

The industry group also advised CMS to include a beneficiary attestation option for all accountable care organization tracks under Medicare. CMS intends to implement an automated mechanism for beneficiaries to voluntary sign up for ACO participation

“AMGA supports this proposal for all ACO tracks,” AMGA wrote. “This would not only enhance the attribution process, by reducing unstable assignment or year-over-year patient churn, it would also recognize patient choice and likely make patients more engaged in the care they receive.”

In the letter commenting on the proposed 2017 Hospital Outpatient Prospective Payment System, AMGA suggested that CMS be more flexible with determining if off-campus provider-based departments are exempted from site-neutral payments and allow claims billed three years before November 2, 2015 to be exempted from lower site-neutral rates.

“CMS should be open to evaluating and granting a limited number of relocation requests particularly if they provide evidence demonstrating significant improvement in existing or exempted patient care,” wrote the organization.

The industry group also asked CMS to eliminate the proposal to remove the pain management dimension of the Hospital Consumer Assessment of Health Plans Survey that contributes to payment adjustments under the Hospital Value-Based Purchasing Program. No scientific studies confirm that survey responses influence inappropriate prescribing habits for pain.

On the other hand, AMGA did voice support for some proposed changes to the Medicare hospital outpatient reimbursement program, including a continuous 90-day EHR reporting period for all eligible professionals, removal of beneficiary authorization requirements for electronic communication of medical data with other treating providers as a condition for payment, and additional public reporting on performance measurements on CMS websites.

“AMGA is pleased that CMS included in its proposals a 90-day reporting period in 2016 eligible professionals,” said Fisher. “As AMGA has stated in previous comments, this change will provide for a smooth transition for both providers and EHR vendors toward a more effective EHR system.”

“AMGA also supports to move toward increased transparency in the hospital outpatient quality reporting,” Fisher continued. “Both providers and patients will benefit from the availability of the performance data.”

CMS closed the comment period on both proposed Medicare reimbursement systems on September 6 and it intends to review all comments before finalizing any changes.

Dig Deeper:

• What is Value-Based Care, What It Means for Providers?

• 8 Tips for Avoiding Denials, Improving Claims Reimbursement